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ANXIETY DISORDER
ANXIETY
• A subjective and individual experience characterized by feeling of
apprehension, uneasiness, uncertainty, or dread that warns a person of
actual or imagined, misperceived or misinterpreted danger. It is often
preceded by new and unknown situations or experiences that threaten the
security, self-concept, self-esteem or identity of the person.
• It is manifested by both psychological and physiological symptoms
• It is a normal response to stressor but no identifiable, specific or certain
cause
TYPES of ANXIETY
1. Normal – a healthy type of anxiety that mobilizes a person to action
2. Acute – precipitated by imminent loss or change that threatens the sense
of security
3. Chronic – anxiety that the individual has lived with for a long time
LEVELS OF ANXIETY
NURSING INTERVENTIONS
CALM
• Calm the client
• Administer anxiolytics
• Listen to patient’s concern
• Minimize environmental stimuli
ANTI-ANXIETY AGENTS
• Also known as anxiolytics or minor tranquillizers
• Benzodiazepines are the most commonly used and most effective
medications for treatment of anxiety.
• Facilitate sleep
• Alcohol is the oldest drug to be used to reduce anxiety.
3 Gerald T. Evangelista, RN, MAN
Psychiatric Nursing: ANXIETY DISORDER
Mechanism of Action
• Depression of the central nervous system
BENZODIAZEPINES
• Alprazolam (Xanax)
• Chlordiazepoxide (Librium)
• Clonazepam (Klonopin)
• Diazepam (Valium)
• Flurazepam (Dalmane)
• Lorazepam (Ativan), usually administer for elderly
• Oxazepam (Serax), usually administer for elderly
Indications of Benzodiazepines
• Anxiety
• Sedation/sleep
• Muscle spasm
• Seizure disorder
• Alcohol withdrawal symptoms
BENZODIAZEPINES
• Prolonged use may lead to dependency and abuse
• They appear to increase the effectiveness of GABA and may also alter the
brain’s metabolism of serotonin and norepinephrine
• All benzodiazepines are readily absorbed in the GI tract after oral
administration
• The onset of action is very rapid and peak levels are often reached within an
hour or less
PATIENT TEACHING
• Benzodiazepines are not for the minor stresses of everyday life.
• Over-the-counter drug may potentiate the actions of benzodiazepines
• Driving should be avoided until tolerance develops
• Alcohol and other CNS depressants potentiate the effects of benzodiazepine
BUSPIRONE (BuSpar)
• Is not a benzodiazepine but is from the azapirones chemical group
• Does not bind to the benzodiazepine recognition sites but probably acts as
serotonin agonist
• It causes no sedation thus makes it less attractive for abuse; not habit
forming
• Not a controlled substance
• Does not potentiate the depressant effects of alcohol, barbiturates and other
CNS drugs
• Because it does not induce an immediate calming effect it should not be
used as a prn medication for anxiety
• Because of its high cost and slow onset of action, buspirone is not widely
prescribed
• Haldol and MAOIs may cause some adverse effects when co-administered
PROPANOLOL (Inderal)
• Beta-blockers have a calming effect on the CNS
• Effectively interrupts the physiological responses of anxiety (tremors &
tachycardia)
• Less effective than benzodiazepines
• Relatively safe
• Little abuse potential
• Bradycardia, light-headedness, and heart block
ANXIETY DISORDERS
• Know as neurotic disorders
• A group of conditions that share a key feature of excessive anxiety with
ensuing behavioral, emotional and physiologic responses
• Most common of all psychiatric disorders
• The defense mechanism used are repression, displacement and
symbolization
• Types:
1) General Anxiety Disorder (GAD)
2) Panic disorder
3) OCD
4) Phobic disorder
5) PTSD
INCIDENCE
• Highest prevalence rate of all mental disorders in the US
• More prevalent in women
• People younger than 45 years old
• People who are separated or divorced
• Lower socioeconomic status
• Exception in OCD, which is equally prevalent in men and women, but more
prevalent among boys than girls
b. Neurochemical theories
• GABA
• An inhibitory neurotransmitter
• Increases anxiety
• SEROTONIN
• Related to OCD
2. PSYCHODYNAMIC THEORIES
A. Psychoanalytic theories
• Person’s innate anxiety is the stimulus for behavior
• Defense mechanisms are used in an attempt to reduce anxiety
B. Interpersonal Theories
• Anxiety is generated from problems in interpersonal relationships
• The higher the level of anxiety, the lower the ability to communicate and to
solve problems
C. Behavioral Theory
• Anxiety is learned through experiences
• Responses to stressors are often the result of learned or conditioned
behavior
• Individuals who experienced intense fear early in life are likely to be anxious
later in life
• When individuals experience too many life changes over a short period of
time, they may be unable to adjust and may display maladaptive behavior
• Restlessness
• Easily fatigued
• Difficulty concentrating
• Sleep disturbance
• Irritability
• Muscle tension
9 Gerald T. Evangelista, RN, MAN
Psychiatric Nursing: ANXIETY DISORDER
NURSING DIAGNOSIS
• Anxiety related to feeling of helplessness
• Fatigue related to insomnia
• Disturbed sleep pattern related to inability to relax
• Ineffective health maintenance related to inattention to activities of daily living
(ADLs)
• Impaired social interaction related to withdrawal from social contracts
NURSING INTERVENTIONS
• Assists the patient in identifying events that tend to increase anxiety and
events during which the patient experiences relative internal calm
• Engage the patient in anticipatory planning
• Teach the patient about relaxation techniques, and practice them with the
patient
• Help the patient work on the problem one at a time
• Accompany the patient to activities that the patient is too anxious to attend
alone
• Instruct the patient in the use of sensory interventions, such as music
therapy or aroma therapy
TREATMENT
• Relaxation training (breathing exercises, progressive muscle relaxation,
guided imagery)
• Benzodiazepine therapy (early phase of treatment, optional)
• Selective serotonin reuptake inhibitors
• Psychotherapy
• Education
PANIC DISORDER
• Characterized by panic attacks that recur at unpredictable times
• Readily distinguished from GAD by its intensity and rapid, powerful onset
• Between panic attacks, the individual may have little or no debilitating anxiety
or may suffer from chronic anxiety about future attacks
• Usually lasts between 1 minute and 1 hour
• The onset is sudden and the source of anxiety may not be identifiable
• Individuals with panic attacks frequently associate their symptoms with
physical illness and are concerned about death
• Feelings of hopelessness, helplessness and despair may lead to suicidal
ideations
• Three serious effects often occurs when left untreated
1. Avoidance – in effort to avoid attack, the person avoids activities, places,
people or situations that he thinks trigger the attacks
2. Agoraphobia – soon the person fears and avoid public places where he
thinks he has no escape when panic attack occurs
3. Anticipatory Anxiety – the client develop intense anxiety between
episodes, worrying when and where the next one will strike.
• Characterized by the rapid onset of fear, terror and discomfort accompanied
by at least 4 of the following manifestations:
CLINICAL SYMPTOMS
4. Palpitations, pounding heart, or accelerated heart rate
5. Diaphoresis
6. Shortness of breath
7. Feeling of choking
11 Gerald T. Evangelista, RN, MAN
Psychiatric Nursing: ANXIETY DISORDER
NURSING INTERVENTIONS
• Remain calm
• Remain with the client during attack
• Do not touch the client during an attack
• Offer reassurance
• Use short clear sentences
• Provide safety
• Reduce environmental stimuli
• Administer medication
• Help the patient find a pattern to the attacks
TREATMENT
• Benzodiazepine (such as Alprazolam [Xanax])
OBSESSIVE-COMPULSIVE DISORDER
• Characterized by
recurrent obsessions or
compulsions that
interferes with normal life
• Inability to control the
thoughts and behaviors
despite the recognition
by the person of their
absurdity and intensity
OBSESSION
• Recurrent, persistent
thoughts, ideas, images
or impulses that are a
significant source of
distress
COMPULSION
13 Gerald T. Evangelista, RN, MAN
Psychiatric Nursing: ANXIETY DISORDER
COMMON OBSESSIONS
• Contamination
• Questions
• Order
• Sex
• Aggressive feelings
• Religion
• Exactness
• Safety or harm
COMMON COMPULSIONS
• Counting
• Praying
• Handwashing
• Repeating words
• Checking
NURSING INTERVENTIONS
14 Gerald T. Evangelista, RN, MAN
Psychiatric Nursing: ANXIETY DISORDER
• Alleviate anxiety
• Provide time for client to carry out rituals
• Don’t interrupt a ritual after it has started; to do so could result in panic-level
anxiety
• Initially, support the behavior until adaptive constructive behavior can be
gradually modified.
• Avoid punishment and criticisms
• Allow episodes of compulsive acts but set limit to prevent harmful acts
TREATMENT
• Behavioral techniques
• Desensitization, or gradual exposure (having the patient gradually
engage in anxiety-provoking activities or situations)
• Modeling of desired behavior (showing the patient how to respond to a
bothersome stimuli)
• Response delay (having the patient wait for increasingly longer intervals
before engaging in ritualistic behaviors)
• Cognitive therapy such as thought stopping (having the patient willfully
interrupt unwanted, anxiety-producing thoughts by engaging in competing,
activity or by yelling “stop”
• Antidepressants (such as Paroxetine [Paxil])
• Nonreinforcement of secondary gains
ACUTE PTSD
• Less than 3 months after the event
CHRONIC PTSD
• 3 months or more after the event
DELAYED PTSD
• At least 6 months after the event
CLINICAL MANIFESTATIONS
• Flashbacks
• Nightmares
• Acting or feeling as if the events were recurring
16 Gerald T. Evangelista, RN, MAN
Psychiatric Nursing: ANXIETY DISORDER
NURSING DIAGNOSIS
• Post-trauma syndrome related to the traumatic experience
• Risk for self-directed violence related to anger and self-blame over the event
• Disturbed sleep pattern related to persistent dreams about the event
• Anxiety related to feelings of insecurity and being unsafe
NURSING INTERVENTIONS
• Encourage the patient to recall the traumatic event; remain non-judgmental
and accept what the patient is saying
• Provide a secure environment for the patient to promote a sense of safety.
• Remain with the patient, especially one who’s extremely anxious; re-
experiencing the traumatic event can trigger severe or panic anxiety
• Institute suicide precautions if the patient manifests suicidal tendencies
• Facilitate grieving by encouraging the patient to express emotions generated
from the event
• Teach the patient and family about posttraumatic behavior, and refer them to
support groups for additional help
TREATMENT
• Psychotherapy (directed toward helping the patient achieve cognitive
mastery over the traumatic situation)
• Benzodiazepine therapy (may be prescribed to manage uncontrollable
anxiety)
• Anti-depressant therapy
PHOBIC DISORDER
• Individuals with phobic disorders recognize that their phobias (fears of
specific objects, activities and situations) are irrational
• Contact with the feared stimuli, or mere thought of the stimuli, causes
immediate, severe anxiety
• Individuals with phobic disorder attempt to manage their anxiety by avoiding
the feared stimuli
• Most common form of anxiety disorders
• Individual experiences intermittent anxiety which arises in particular
circumstances (in response to the phobic object or situation)
• Avoidance of the feared stimuli may drastically interfere with routine activities
• Inability of the person to overcome the fear, despite the recognition that the
fear is absurd.
• Willingness of the person to do anything to avoid the phobic object, person,
or event, regardless of the consequences
TYPES OF PHOBIA
• SOCIAL PHOBIA
• AGORAPHOBIA
• SIMPLE PHOBIA OR SPECIFIC PHOBIA
SOCIAL PHOBIA
• Also called Social Anxiety Disorder
• Excessive fear of embarrassment and humiliation in public settings
• Social phobias strain interpersonal relationships and the phobic individual
may become more anxious when SO attempt to provide support and
assistance
• Treatment with Alprazolam and exposure therapy
• Dating
• Speaking to store clerks
• Speaking to authority figure
AGORAPHOBIA
• An irrational fear of being in places away from the familiar setting of home, in
crowds, or in situations that patient cannot leave easily such as standing in
line, being on a bridge, and traveling in a plane, bus ,train, or car.
• Clients may fear leaving their home.
SIMPLE PHOBIA
• Also called SPECIFIC PHOBIA
• The most common specific phobia in the general population is fear of
animals – particularly of dogs, snakes, insect and mice
• Unrealistic fear of a particular object or situation
• Panic level anxiety may be experienced
• An irrational fear of an object, activity or situation that is out of proportion to
the stimulus and results in avoidance of the identified object, activity, or
situation.
NURSING DIAGNOSIS
• Fear related to an irrational feeling toward something harmless
• Powerlessness related to an inability to control the fear
• Social isolation related to self-protected avoidance
NURSING INTERVENTION
• Never force the patient to contact the phobic object; such contact may
precipitate a panic attack
• Reassure the patient that he won’t be forced to confront the phobic situation
• Initially, adjust the environment to
accommodate the patient’s
phobia; as treatment progresses,
adjustment won’t be necessary
TREATMENT
• Social skills training
• Behavioral therapy